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John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently had lunch with an EHR vendor that had an extremely small number of providers. I’ve known this EHR vendor for about 5 years, so this isn’t a new EHR vendor that’s trying to establish themselves in the industry. Instead they’ve focused on having a small, nimble team that’s focused on making the EHR work the right way for the doctors. It’s a novel approach I know, but pretty interesting that his business can survive with so few providers. Also worth noting is that the EHR is certified for meaningful use stage 2 as well.

Now think for a minute how the development process of an EHR vendor would be better if your EHR only had 25 doctors (For the record, the EHR vendor above has a few more than 25 doctors). Would it be much easier to satisfy just 25 physician users? Imagine the personalized service you could provide your users.

One of the real challenges I’ve seen with EHR vendors is that when they’re small, they are extremely responsive to their end users and the end users are very happy. As the EHR vendor grows, they lose that personal touch with the end users and many of those originally happy end users become dissatisfied with their EHR experience.

The problem with scaling an EHR user base is that you can’t make everyone happy. You have to make compromises that will be great in some people’s eyes and terrible in another person’s mind. What large EHR vendors do to try and solve this problem is they create configurable options that allow the end user to customize their system to meet their personal needs. Problem solved, right?

The problem with these configurations is two fold. First, you can’t make everything configurable. Once you go down the path of making everything configurable, it never ends. There’s always something else that could be made more configurable. So, the culture of configurability leads to unsatisfied users who can’t customize everything (even if what they want to customize shouldn’t matter).

Second, if everything is configurable, then it makes the implementation that much more complex. I’ve written before about the need for EHR vendors to have great “out of the box” user experience, but balancing that with allowing the user to configure everything that’s needed. This is a real challenge and most fail. Just look at the number of high priced EHR consulting companies out there. Many of them could better be defined as EHR configuration companies since the configuration needs are so large and complex.

Returning to where we started, when you’re an EHR vendor with 25 doctors you don’t have to build in all the flexibility and configurability. You’re small enough that as an EHR vendor you can do any needed customizations and configurations for the end user. Plus, with this kind of personalized service you can charge a little extra as well.

When you look at EHR development, there’s a spectrum of approaches starting with a fully in house, custom designed EHR through a fully outsourced EHR that can apply to any organization or specialty. In many ways a 25 doctor EHR has a lot of the same benefits of a fully custom EHR software, but spreads the costs of development across more doctors.

As a business, maybe a 25 doctor EHR company won’t dominate the world. Maybe they won’t have a huge exit to some other company or an IPO. However, that doesn’t mean it’s not a great small business if it’s doing something you love. Once you get World Domination out of your sites, it changes a lot of things about how you do business.

10 responses to "What If Your EHR Only Had 25 Doctors?"

This is a classic challenge for any business as they grow.
The challenge/issue EHR vendors have no matter the user base size is that of customization.
It is the classic example of too many choices causes problems.
Ever been to a restaurant with one of those Coke machines that has a million selections? Notice how long the lines gets?
Well, most EHR vendors have a “reference” setup that, in theory, is an optimal set of processes for a practice to follow.
The issue is, most docs have reinvented the wheel and don’t want to change the way they do things.
Hence the unrelenting customization challenge.
In the end, to simplify all of this one of two things will have to happen:
1) Docs conform to a “reference” set of processes based on specialty
2) Vendors have bigger customization team for the never ending customization

While the article describes the interaction between the vendor and the medical client, with respect to customizability and reconfiguration within the respective applications, it fails to describe the other entities who have equal places at the EHR design, configuration and customization conference table.

Designing an EHR is not defined or regulated to just the vendor and the medical client,(hospital or private physician office). The article has left out the federal stipulations and criteria that qualify an EHR for Meaningful Use Incentive dollars as well as the interoperability capacity when it comes to HIE mandates.

There are a host of personnel associated with the various medical governing and licensing boards. JACHO, CMS, AMA, HIPPA, APC, ICD-9-10, federal/state medical policy and procedure auditors, medical insurance companies, ACA, to name a few. All of these agencies have a seat at the design table.

Even in the prior paper, hardcopy process, certain forms, procedures, order protocol, pharmaceutical administration document requirements, lab testing and posting of results and the like were all governed by a host of agencies and departments.

The EHR is governed by prior and newly addended rules and regulations. The new EHR is a cooperative culmination of the needs and required criteria of all the above listed. In the Hard copy era, the above agencies adapted themselves to the hospital’s documentation format, to a certain degree, but wit the EHR the hospitals and the agencies have a stand alone national standardized electronic health documentation system that all participating parties can refer to for all their respective duties in and around patient care, the proper documentation of said care, the billing and reimbursement of care as well as referral, review and reporting needs for a national health perspective

Healthcare is not a two party business any longer. All who are affiliated are now held to the new national standard documentation process.

EHR workflow should be customizable without requiring direct involvement of computer programmers working for EHR vendors. Other industries support customizable workflow. Eventually healthcare will too.

Good discussion and comments. On another subject, you also wonder – what if… what if the fact that the vendor has a small number of clients is not a matter of choice but a reality beyond their control?

What I mean is, with unrelenting competition, it is hard to imagine someone makes the ‘choice’ of remaining small with just 25 clients.

Unless, of course, you have created a tremendous value proposition where practices are willing to pay a very large premium for your product and services. In which case, you are doing the perfect thing of targeting clients that prefer value, and you are selling a high-end product versus commodity.

@ Charles:
While I agree, I believe that is something that drag & drop just won’t quite get to.
Heck, people still have trouble with Word & Excel.
Plus, the biggest issue I see in this area is practices haven’t even mapped out their processes.
Until they do this, nothing else can…properly…happen.

Folks map out processes all the time in tools such as Visio. Why not map out processes in such a way that the process maps actually drive EHR behavior? The problem isn’t that folks don’t know how to draw their workflow, it’s that their effort does not translate sufficiently quickly to something practical. Health IT simply most move from the structured document-based systems that slow physicians down, to structured workflow systems to make them more productive.

Chandresh,
You can usually tell the difference between a company that wants to be big and only has 25 customers and one that has 25 and doesn’t really want to grow much bigger. It’s a totally different mentality. The later are much rarer though.

The issue isn’t really whether visual tools are used or not. The issue is whether users can customize their workflow to their needs and liking without breaking something. Traditional EHRs and HIT systems do not manage workflow, in the sense that much workflow is implicitly coded in the textual code written, modified, and compiled by traditional programmers. You literally must redesign the EHR to redesign workflow. Compare this sad situation with workflow management systems, business process management, and adaptive case management software. In these systems users, or folks (who are not necessarily programmers themselves) working closely with users, such as business and clinical analysts can proceed more quickly from understanding workflow to implementing workflow. In fact, since workflow can be so easily customized, instead of tremendous investments of workflow analysis up front (because the cost of being wrong is so high), approximately correct workflow can be put in to place, and then tweaked and retweaked until just right.

Workflow-oblivious Health IT is literally decades behind other industries in the use of this kind of process-aware information technology.

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